Compositions and methods for treatment and delaying the onset of diabetes

ABSTRACT

Disclosed herein are methods of delaying the onset or treating diabetes that comprises administering a uric acid lowering agent. The inventors have made the remarkable discovery that elevated uric acid levels are not a corollary to insulin resistance, but rather a primary mediator of insulin resistance. Specifically exemplified are methods that involve administering to a patient susceptible to development of diabetes a composition comprising a uric acid lowering agent in a regimen that maintains serum uric acid levels below at least 5.2 to 5.5 mg/dl.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation of U.S. application Ser. No.11/572,270 filed Jan. 18, 2007, issued as U.S. Pat. No. 8,557,831, towhich priority is claimed under 35 USC 120. This application also claimsbenefit under 35 USC 119 of the Jul. 21, 2004, filing date of U.S.provisional patent application No. 60/589,921. The foregoingapplications being incorporated herein in their entirety.

BACKGROUND OF THE INVENTION

Diabetes mellitus is characterized by a broad array of physiologic andanatomic abnormalities, for example, altered glucose disposition,hypertension, retinopathy, abnormal platelet activity, aberrationsinvolving large, medium and small sized vessels, and other problemsencountered in diabetic patients. Diabetes is classified into twocategories: primary and secondary. Primary diabetes includes: 1)Insulin-dependent diabetes mellitus (IDDM, Type 1), 2)Non-insulin-dependent diabetes mellitus (NIDDM), Type 2) including a)Nonobese NIDDM, b) Obese NIDDM and c) Maturity-onset diabetes of theyoung. Primary diabetes implies that no associated disease is present,while in the secondary diabetes some other identifiable condition causesor allows a diabetic syndrome to develop, for example, 1) Pancreaticdisease, 2) Hormonal abnormalities, 3) Drug or chemical induced, 4)Insulin receptor abnormalities, 5) Genetic syndromes and 6) Others.

Insulin dependence in this classification is not equivalent to insulintherapy, but means that the patient is at risk for ketoacidosis in theabsence of insulin. It has been suggested that the termsinsulin-dependent and non-insulin-dependent describe physiologic states(ketoacidosis-prone and ketoacidosis-resistant, respectively), while theterms Type 1 and Type 2 refer to pathogenetic mechanisms(immune-mediated and non-immune-mediated, respectively). Using thisclassification, three major forms of primary diabetes are recognized:(1) type 1 insulin-dependent diabetes, (2) type 1 non-insulin-dependentdiabetes, and (3) type 2 l non-insulin-dependent diabetes.

Secondary forms of diabetes encompass a host of conditions such aspancreatic disease, hormonal abnormalities, genetic syndromes, andothers.

Insulin-dependent diabetes mellitus often develops in childhood oradolescence while the onset of NIDDM generally occurs in middle or latelife. Patients with NIDDM are usually overweight and constitute 90 to 95percent of all diabetics. IDDM results from the destruction of betacells by an autoimmune process that may be precipitated by a viralinfection. NIDDM is characterized by a gradual decline in beta cellfunction and varying degrees of peripheral resistance to insulin. Theannual incidence of IDDM ranges from 10 cases per 100,000 persons fornonwhite males to 16 cases per 100,000 persons for white males. LaPorte,R. E. et al., 1981, Diabetes 30: 279. The prevalence of NIDDM increaseswith age, especially after age 45 and is higher among blacks than whitesand certain populations such as Asian Indians living in South Africa andEngland. Malter, H. M. et al., 1985, Br. Med. J. 291: 1081. Gestationaldiabetes occurs in 2.4 percent of all pregnancies in the United Statesannually. Freinkel, N. et al., 1985, N. Engl. J. Med. 313: 96. Pregnancyis also a state of insulin resistance. This insulin resistance isexacerbated in gestational diabetes which may predispose patients to thevarious hypertensive syndromes of pregnancy associated with Type 2NIDDM. Bardicef, M. et al., 1995, Am. J. Gynecol. 172: 1009-1013.

Current therapies for IDDM include insulin therapy, and for NIDDM willinclude dietary modification in a patient who is overweight andhypoglycemic agents, e.g., tolbutamide, chlorpropamide, acetohexamide,tolazamide, glipizide and glyburide, all of which act by stimulating therelease of insulin from the beta cells.

Insulin resistance and hyperuricemia are considered a part of the‘metabolic syndrome’ or ‘syndrome X’ of obesity, insulin resistance,hypertriglyceridemia and hyperuricemia, which underlies the pathogenesisof type II diabetes. Insulin resistance is an impaired metabolicresponse to our body's own insulin so that active muscle cells cannottake up glucose as easily as they should. In that situation, the bloodinsulin levels are chronically higher which inhibits our fat cells fromgiving up their energy stores to let us lose weight. The condition canexist unrecognized and metabolic damage can occur before a full blownType 2 diabetes is finally diagnosed. Insulin resistant diabetics are2-5 times more likely to die from heart attack or stroke than are nondiabetics. Currently metabolic syndrome is epidemic both in the UnitedStates and throughout the world, resulting in exponential increases inhealth care cost and causing great morbidity and mortality due to theincreased risk for cardiovascular and renal disease in this population.Most studies suggest that the epidemic is due to the adaptation of‘Westernized diet’—this diet is also known to increase our risk for gout(Johnson R J, Rideout B: Uric acid and diet: insights into the Epidemicof Cardiovascular Disease. N Engl J Med (editorial) 2004;350:1071-1074).

It has widely been assumed that the rise in serum uric acid associatedwith insulin resistance is due to the effect of insulin to increaseurate reabsorption in the renal tubule, and hence it had been assumedthat the hyperuricemia associated with insulin resistance does not havea causal role in the syndrome.

SUMMARY OF THE INVENTION

The inventors have made the remarkable discovery that elevated levels ofuric acid is a primary mediator of insulin resistance. The subjectinvention provides a new approach to preventing and/or treating theinsulin resistance and diabetes.

In a specific embodiment, the subject invention pertains to methods ofadministering a uric acid lowering agent (UALA) to a patient susceptibleto developing insulin resistance or suffering from insulin resistance.As part of the medical treatment, serum samples are typically obtainedand tested so that serum uric acid levels may be monitored inconjunction with the administration of the UALA.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a graph showing the relationship of serum uric acid and serumnitrites at 1 and 7 Days of hyperuricemic induced rats. Serum wasanalyzed for uric acid concentration and nitrites / nitrates (NO_(x)) bychemiluminescence method.

FIG. 2 represents a graph that shows the linear correlation of serumuric acid and serum nitrites.

DETAILED DESCRIPTION OF THE INVENTION

The pharmaceutical compositions provided herein contain therapeuticallyeffective amounts of one or more agents to lower uric acid that areuseful in the treatment or prevention of insulin resistance. Theinventors have discovered that hyperuricemia plays a critical role incausing insulin resistance.

The term “uric acid lowering agent” or UALA refers to substances knownto lower serum uric acid levels in mammals. Typically, the UALA maylimit serum uric acid levels by at least about 0.2 mg/dl. UALAs include,but are not limited to, xanthine oxidase inhibitors such as allopurinol,hydroxyakalone, TEI-6720, carprofen, febuxostat, and y-700; uricosuricssuch as benziodarone, benzbromarone, probenecid; uricase derivativessuch as Rasburicase and Pegylated uricase; gene based therapies such asuricase overexpression or blockade of URAT-1; a supplement of theuricase protein which might be delivered as a conjugate withpolyethylene glycol or another delivery system; and a urate channelinhibitor.

The compounds are preferably formulated into suitable pharmaceuticalpreparations such as solutions, suspensions, tablets, dispersibletablets, pills, capsules, powders, sustained release formulations orelixirs, for oral administration or in sterile solutions or suspensionsfor parenteral administration, as well as transdermal patch preparationand dry powder inhalers. Typically the compounds described above areformulated into pharmaceutical compositions using techniques andprocedures well known in the art (see, e.g., Ansel Introduction toPharmaceutical Dosage Forms, Fourth Edition 1985, 126).

In the compositions, effective concentrations of one or more compoundsor pharmaceutically acceptable derivatives is (are) mixed with asuitable pharmaceutical carrier or vehicle. The compounds may bederivatized as the corresponding salts, esters, enol ethers or esters,acids, bases, solvates, hydrates or prodrugs prior to formulation, asdescribed above. The concentrations of the compounds in the compositionsare effective for delivery of an amount, upon administration, thatreduces serum uric acid levels at least 0.5 mg/dl to be equal to or lessthan 5.5 mg/dl. In a most preferred embodiment, effective amount is suchas to lower serum uric acid levels to less than or equal to 5.5 mg/dland more than or equal to 4.0 mg/dl. Preferably still, the effectiveamount is such as to lower serum uric acid levels to less than or equalto 5.2 mg/dl and more than or equal to 4.5 mg/dl. It is known that uricacid acts as antioxidant in the body. Epidemiological studies performedby the inventor have uncovered that the positive effects of avoidinginsulin resistance are achieved by lowering serum uric acid levels to atleast 5.5 mg/dl. However, the positive effects are largely negated asserum uric acid levels fall below 4.0 mg/dl. At levels below 4.0 mg/dl,the loss of antioxidant activity of uric acid may actually predispose toan increased incidence of cardiovascular disease and mortality. The UALAmay be administered concomitantly or sequentially with one or more knownantioxidants, such as, but not limited to, vitamin C, alpha-lipoic acid,Vitamin E, beta carotene, selenium, zinc, carnosine, green tea, soy andisoflavones, tempol, etc. Such combination may be beneficial regardlessof uric acid levels, but may be particularly helpful if dosages of UALAare administered that lower the uric acid below 4.5 mg/dl.

Typically, the compositions are formulated for single dosageadministration. To formulate a composition, the weight fraction ofcompound is dissolved, suspended, dispersed or otherwise mixed in aselected vehicle at an effective concentration such that the treatedcondition is relieved or ameliorated. Pharmaceutical carriers orvehicles suitable for administration of the compounds provided hereininclude any such carriers known to those skilled in the art to besuitable for the particular mode of administration.

The term “average serum uric acid level(s)” as used herein refers to anaverage of two or more uric acid readings obtained from a patient. Thetwo or more uric acid readings may be taken within hours of each other.Preferably, the two or more readings are obtained at least a week fromeach other.

The term “regimen” as used herein refers to an administration of two ormore dosages sequentially spaced in time so as to maintain average serumuric acid levels at a predetermined level. The space in time ispreferably 3 or more hours.

In addition, the compounds may be formulated as the solepharmaceutically active ingredient in the composition or may be combinedwith other active ingredients. Liposomal suspensions, includingtissue-targeted liposomes, particularly tumor-targeted liposomes, mayalso be suitable as pharmaceutically acceptable carriers. These may beprepared according to methods known to those skilled in the art. Forexample, liposome formulations may be prepared as described in U.S. Pat.No. 4,522,811.

The active compound is included in the pharmaceutically acceptablecarrier in an amount sufficient to exert a therapeutically useful effectin the absence of undesirable side effects on the patient treated. Thetherapeutically effective concentration may be determined empirically bytesting the compounds in known in vitro and in vivo systems (see, e.g.,Rosenthal et al. (1996) Antimicrob. Agents Chemother. 40(7):1600-1603;Dominguez et al. (1997) J. Med. Chem. 40:2726-2732; Clark et al. (1994)Molec. Biochem. Parasitol. 17:129; Ring et al. (1993) Proc. Natl. Acad.Sci. USA 90:3583-3587; Engel et al. (1998) J. Exp. Med. 188(4):725-734;Li et al. (1995) J. Med. Chem. 38:5031) and then extrapolated therefromfor dosages for humans.

According to certain embodiments, in the case of preventing or delayingthe onset of diabetes, a patient in need is one who is experiencingsymptom(s) of diabetes. These symptoms are known in the art and includethe following: ketoacidosis, a state of metabolic dysregulationcharacterized by the smell of acetone; a rapid, deep breathing known asKussmaul breathing; nausea; vomiting and abdominal pain; polyuria(frequent urination); polydipsia (increased thirst); polyphagia(increased hunger), increased or decreased insulin levels, or elevatedserum glucose. Additionally, or alternatively, the patient in need fordiabetes is one who is presently taking or in need of insulin treatment.In an even more specific embodiment, the patient in need is a subjectwho is exhibiting one or more of the following symptoms:

-   -   Fasting plasma glucose level ≧7.0 mmol/L (126 mg/dL).    -   Plasma glucose ≧11.1 mmol/L (200 mg/dL) two hours after a 75 g        oral glucose load as in a glucose tolerance test.    -   Symptoms of hyperglycemia and casual plasma glucose ≧11.1 mmol/L        (200 mg/dL).    -   Glycated hemoglobin (Hb AlC) ≧6.5%.

The concentration of active compound in the pharmaceutical compositionwill depend on absorption, inactivation and excretion rates of theactive compound, the physicochemical characteristics of the compound,the dosage schedule, and amount administered as well as other factorsknown to those of skill in the art. For example, the amount that isdelivered is sufficient to lower uric acid concentrations at least 0.5mg/dl to achieve 5.5 mg/dl or lower serum uric acid levels.

Typically a therapeutically effective dosage should produce a serumconcentration of active ingredient of from about 0.1 ng/ml to about50-100 μg/ml. The pharmaceutical compositions typically should provide adosage of from about 0.001 mg to about 2000 mg of compound per kilo-gramof body weight per day. Pharmaceutical dosage unit forms are prepared toprovide from about 1 mg to about 1000 mg and preferably from about 10 toabout 500 mg of the essential active ingredient or a combination ofessential ingredients per dosage unit form.

The active ingredient may be administered at once, or may be dividedinto a number of smaller doses to be administered at intervals of time.It is understood that the precise dosage and duration of treatment is afunction of the disease being treated and may be determined empiricallyusing known testing protocols or by extrapolation from in vivo or invitro test data. It is to be noted that concentrations and dosage valuesmay also vary with the severity of the condition to be alleviated. It isto be further understood that for any particular subject, specificdosage regimens should be adjusted over time according to the individualneed and the professional judgment of the person administering orsupervising the administration of the compositions, and that theconcentration ranges set forth herein are exemplary only and are notintended to limit the scope or practice of the claimed compositions.

Preferred pharmaceutically acceptable derivatives include acids, bases,enol ethers and esters, salts, esters, hydrates, solvates and prodrugforms. The derivative is selected such that its pharmacokineticproperties are superior to the corresponding neutral compound.

Thus, effective concentrations or amounts of one or more of thecompounds described herein or pharmaceutically acceptable derivativesthereof are mixed with a suitable pharmaceutical carrier or vehicle forsystemic, topical or local administration to form pharmaceuticalcompositions. Compounds are included in an amount effective for reducinguric acid at or below 5.5 mg/dl. The concentration of active compound inthe composition will depend on absorption, inactivation, excretion ratesof the active compound, the dosage schedule, amount administered,particular formulation as well as other factors known to those of skillin the art.

The compositions are intended to be administered by a suitable route,including orally, parenterally, rectally, topically and locally. Fororal administration, capsules and tablets are presently preferred. Thecompositions are in liquid, semi-liquid or solid form and are formulatedin a manner suitable for each route of administration. Preferred modesof administration include parenteral and oral modes of administration.Oral administration is presently most preferred.

Solutions or suspensions used for parenteral, intradermal, subcutaneous,or topical application can include any of the following components: asterile diluent, such as water for injection, saline solution, fixedoil, polyethylene glycol, glycerine, propylene glycol or other syntheticsolvent; antimicrobial agents, such as benzyl alcohol and methylparabens; antioxidants, such as ascorbic acid and sodium bisulfite;chelating agents, such as ethylenediaminetetraacetic acid (EDTA);buffers, such as acetates, citrates and phosphates; and agents for theadjustment of tonicity such as sodium chloride or dextrose. Parenteralpreparations can be enclosed in ampules, disposable syringes or singleor multiple dose vials made of glass, plastic or other suitablematerial.

In instances in which the compounds exhibit insufficient solubility,methods for solubilizing compounds may be used. Such methods are knownto those of skill in this art, and include, but are not limited to,using cosolvents, such as dimethylsulfoxide (DMSO), using surfactants,such as TWEEN®, or dissolution in aqueous sodium bicarbonate.Derivatives of the compounds, such as prodrugs of the compounds may alsobe used in formulating effective pharmaceutical compositions.

Upon mixing or addition of the compound(s), the resulting mixture may bea solution, suspension, emulsion or the like. The form of the resultingmixture depends upon a number of factors, including the intended mode ofadministration and the solubility of the compound in the selectedcarrier or vehicle. The effective concentration is sufficient forameliorating the symptoms of the disease, disorder or condition treatedand may be empirically determined.

The pharmaceutical compositions are provided for administration tohumans and animals in unit dosage forms, such as tablets, capsules,pills, powders, granules, sterile parenteral solutions or suspensions,and oral solutions or suspensions, and oil-water emulsions containingsuitable quantities of the compounds or pharmaceutically acceptablederivatives thereof. The pharmaceutically therapeutically activecompounds and derivatives thereof are typically formulated andadministered in unit-dosage forms or multiple-dosage forms. Unit-doseforms as used herein refers to physically discrete units suitable forhuman and animal subjects and packaged individually as is known in theart. Each unit-dose contains a predetermined quantity of thetherapeutically active compound sufficient to produce the desiredtherapeutic effect, in association with the required pharmaceuticalcarrier, vehicle or diluent. Examples of unit-dose forms includeampoules and syringes and individually packaged tablets or capsules.Unit-dose forms may be administered in fractions or multiples thereof. Amultiple-dose form is a plurality of identical unit-dosage formspackaged in a single container to be administered in segregatedunit-dose form. Examples of multiple-dose forms include vials, bottlesof tablets or capsules or bottles of pints or gallons. Hence, multipledose form is a multiple of unit-doses which are not segregated inpackaging.

The composition can contain along with the active ingredient: a diluentsuch as lactose, sucrose, dicalcium phosphate, orcarboxymethylcellulose; a lubricant, such as magnesium stearate, calciumstearate and talc; and a binder such as starch, natural gums, such asgum acaciagelatin, glucose, molasses, polvinylpyrrolidine, cellulosesand derivatives thereof, povidone, crospovidones and other such bindersknown to those of skill in the art. Liquid pharmaceuticallyadministrable compositions can, for example, be prepared by dissolving,dispersing, or otherwise mixing an active compound as defined above andoptional pharmaceutical adjuvants in a carrier, such as, for example,water, saline, aqueous dextrose, glycerol, glycols, ethanol, and thelike, to thereby form a solution or suspension. If desired, thepharmaceutical composition to be administered may also contain minoramounts of nontoxic auxiliary substances such as wetting agents,emulsifying agents, or solubilizing agents, pH buffering agents and thelike, for example, acetate, sodium citrate, cyclodextrine derivatives,sorbitan monolaurate, triethanolamine sodium acetate, triethanolamineoleate, and other such agents. Actual methods of preparing such dosageforms are known, or will be apparent, to those skilled in this art; forexample, see Remington's Pharmaceutical Sciences, Mack PublishingCompany, Easton, Pa., 15th Edition, 1975. The composition or formulationto be administered will, in any event, contain a quantity of the activecompound in an amount sufficient to alleviate the symptoms of thetreated subject.

Dosage forms or compositions containing active ingredient in the rangeof 0.005% to 100% with the balance made up from non-toxic carrier may beprepared. For oral administration, a pharmaceutically acceptablenon-toxic composition is formed by the incorporation of any of thenormally employed excipients, such as, for example pharmaceutical gradesof mannitol, lactose, starch, magnesium stearate, talcum, cellulosederivatives, sodium crosscarmellose, glucose, sucrose, magnesiumcarbonate or sodium saccharin. Such compositions include solutions,suspensions, tablets, capsules, powders and sustained releaseformulations, such as, but not limited to, implants andmicroencapsulated delivery systems, and biodegradable, biocompatiblepolymers, such as collagen, ethylene vinyl acetate, polyanhydrides,polyglycolic acid, polyorthoesters, polylactic acid and others. Methodsfor preparation of these compositions are known to those skilled in theart. The contemplated compositions may contain 0.001%-100% activeingredient, preferably 0.1-85%, typically 75-95%.

The active compounds or pharmaceutically acceptable derivatives may beprepared with carriers that protect the compound against rapidelimination from the body, such as time release formulations orcoatings.

1. Compositions for Oral Administration

Oral pharmaceutical dosage forms are either solid, gel or liquid. Thesolid dosage forms are tablets, capsules, granules, and bulk powders.Types of oral tablets include compressed, chewable lozenges and tabletswhich may be enteric-coated, sugar-coated or film-coated. Capsules maybe hard or soft gelatin capsules, while granules and powders may beprovided in non-effervescent or effervescent form with the combinationof other ingredients known to those skilled in the art.

In certain embodiments, the formulations are solid dosage forms,preferably capsules or tablets. The tablets, pills, capsules, trochesand the like can contain any of the following ingredients, or compoundsof a similar nature: a binder; a diluent; a disintegrating agent; alubricant; a glidant; a sweetening agent; and a flavoring agent.

Examples of binders include microcrystalline cellulose, gum tragacanth,glucose solution, acacia mucilage, gelatin solution, sucrose and starchpaste. Lubricants include talc, starch, magnesium or calcium stearate,lycopodium and stearic acid. Diluents include, for example, lactose,sucrose, starch, kaolin, salt, mannitol and dicalcium phosphate.Glidants include, but are not limited to, colloidal silicon dioxide.Disintegrating agents include crosscarmellose sodium, sodium starchglycolate, alginic acid, corn starch, potato starch, bentonite,methylcellulose, agar and carboxymethylcellulose. Coloring agentsinclude, for example, any of the approved certified water soluble FD andC dyes, mixtures thereof; and water insoluble FD and C dyes suspended onalumina hydrate. Sweetening agents include sucrose, lactose, mannitoland artificial sweetening agents such as saccharin, and any number ofspray dried flavors. Flavoring agents include natural flavors extractedfrom plants such as fruits and synthetic blends of compounds whichproduce a pleasant sensation, such as, but not limited to peppermint andmethyl salicylate. Wetting agents include propylene glycol monostearate,sorbitan monooleate, diethylene glycol monolaurate and polyoxyethylenelaural ether. Emetic-coatings include fatty acids, fats, waxes, shellac,ammoniated shellac and cellulose acetate phthalates. Film coatingsinclude hydroxyethylcellulose, sodium carboxymethylcellulose,polyethylene glycol 4000 and cellulose acetate phthalate.

If oral administration is desired, the compound could be provided in acomposition that protects it from the acidic environment of the stomach.For example, the composition can be formulated in an enteric coatingthat maintains its integrity in the stomach and releases the activecompound in the intestine. The composition may also be formulated incombination with an antacid or other such ingredient.

When the dosage unit form is a capsule, it can contain, in addition tomaterial of the above type, a liquid carrier such as a fatty oil. Inaddition, dosage unit forms can contain various other materials whichmodify the physical form of the dosage unit, for example, coatings ofsugar and other enteric agents. The compounds can also be administeredas a component of an elixir, suspension, syrup, wafer, sprinkle, chewinggum or the like. A syrup may contain, in addition to the activecompounds, sucrose as a sweetening agent and certain preservatives, dyesand colorings and flavors.

The active materials can also be mixed with other active materials whichdo not impair the desired action, or with materials that supplement thedesired action, such as antacids, H2 blockers, and diuretics. The activeingredient is a compound or pharmaceutically acceptable derivativethereof as described herein. Higher concentrations, up to about 98% byweight of the active ingredient may be included.

Pharmaceutically acceptable carriers included in tablets are binders,lubricants, diluents, disintegrating agents, coloring agents, flavoringagents, and wetting agents. Enteric-coated tablets, because of theenteric-coating, resist the action of stomach acid and dissolve ordisintegrate in the neutral or alkaline intestines. Sugar-coated tabletsare compressed tablets to which different layers of pharmaceuticallyacceptable substances are applied. Film-coated tablets are compressedtablets which have been coated with a polymer or other suitable coating.Multiple compressed tablets are compressed tablets made by more than onecompression cycle utilizing the pharmaceutically acceptable substancespreviously mentioned. Coloring agents may also be used in the abovedosage forms. Flavoring and sweetening agents are used in compressedtablets, sugar-coated, multiple compressed and chewable tablets.Flavoring and sweetening agents are especially useful in the formationof chewable tablets and lozenges.

Liquid oral dosage forms include aqueous solutions, emulsions,suspensions, solutions and/or suspensions reconstituted fromnon-effervescent granules and effervescent preparations reconstitutedfrom effervescent granules. Aqueous solutions include, for example,elixirs and syrups. Emulsions are either oil-in-water or water-in-oil.

Elixirs are clear, sweetened, hydroalcoholic preparations.Pharmaceutically acceptable carriers used in elixirs include solvents.Syrups are concentrated aqueous solutions of a sugar, for example,sucrose, and may contain a preservative. An emulsion is a two-phasesystem in which one liquid is dispersed in the form of small globulesthroughout another liquid. Pharmaceutically acceptable carriers used inemulsions are non-aqueous liquids, emulsifying agents and preservatives.Suspensions use pharmaceutically acceptable suspending agents andpreservatives. Pharmaceutically acceptable substances used innon-effervescent granules, to be reconstituted into a liquid oral dosageform, include diluents, sweeteners and wetting agents. Pharmaceuticallyacceptable substances used in effervescent granules, to be reconstitutedinto a liquid oral dosage form, include organic acids and a source ofcarbon dioxide. Coloring and flavoring agents are used in all of theabove dosage forms.

Solvents include glycerin, sorbitol, ethyl alcohol and syrup. Examplesof preservatives include glycerin, methyl and propylparaben, benzoicadd, sodium benzoate and alcohol. Examples of non-aqueous liquidsutilized in emulsions include mineral oil and cottonseed oil. Examplesof emulsifying agents include gelatin, acacia, tragacanth, bentonite,and surfactants such as polyoxyethylene sorbitan monooleate. Suspendingagents include sodium carboxymethylcellulose, pectin, tragacanth, Veegumand acacia. Diluents include lactose and sucrose. Sweetening agentsinclude sucrose, syrups, glycerin and artificial sweetening agents suchas saccharin. Wetting agents include propylene glycol monostearate,sorbitan monooleate, diethylene glycol monolaurate and polyoxyethylenelauryl ether. Organic adds include citric and tartaric acid. Sources ofcarbon dioxide include sodium bicarbonate and sodium carbonate. Coloringagents include any of the approved certified water soluble FD and Cdyes, and mixtures thereof. Flavoring agents include natural flavorsextracted from plants such fruits, and synthetic blends of compoundswhich produce a pleasant taste sensation.

For a solid dosage form, the solution or suspension, in for examplepropylene carbonate, vegetable oils or triglycerides, is preferablyencapsulated in a gelatin capsule. Such solutions, and the preparationand encapsulation thereof, are disclosed in U.S. Pat. Nos 4,328,245;4,409,239; and 4,410,545. For a liquid dosage form, the solution, e.g.,for example, in a polyethylene glycol, may be diluted with a sufficientquantity of a pharmaceutically acceptable liquid carrier, e.g., water,to be easily measured for administration.

Alternatively, liquid or semi-solid oral formulations may be prepared bydissolving or dispersing the active compound or salt in vegetable oils,glycols, triglycerides, propylene glycol esters (e.g., propylenecarbonate) and other such carriers, and encapsulating these solutions orsuspensions in hard or soft gelatin capsule shells. Other usefulformulations include those set forth in U.S. Pat. Nos. Re 28,819 and4,358,603.

In all embodiments, tablets and capsules formulations may be coated asknown by those of skill in the art in order to modify or sustaindissolution of the active ingredient. Thus, for example, they may becoated with a conventional enterically digestible coating, such asphenylsalicylate, waxes and cellulose acetate phthalate.

2. Injectables, Solutions and Emulsions

Parenteral administration, generally characterized by injection, eithersubcutaneously, intramuscularly or intravenously is also contemplatedherein. Injectables can be prepared in conventional forms, either asliquid solutions or suspensions, solid forms suitable for solution orsuspension in liquid prior to injection, or as emulsions. Suitableexcipients are, for example, water, saline, dextrose, glycerol orethanol. In addition, if desired, the pharmaceutical compositions to beadministered may also contain minor amounts of non-toxic auxiliarysubstances such as wetting or emulsifying agents, pH buffering agents,stabilizers, solubility enhancers, and other such agents, such as forexample, sodium acetate, sorbitan monolaurate, triethanolamine oleateand cyclodextrins. Implantation of a slow-release or sustained-releasesystem, such that a constant level of dosage is maintained (see, e.g.,U.S. Pat. No. 3,710,795) is also contemplated herein. The percentage ofactive compound contained in such parenteral compositions is highlydependent on the specific nature thereof, as well as the activity of thecompound and the needs of the subject.

Parenteral administration of the compositions includes intravenous,subcutaneous and intramuscular administrations. Preparations forparenteral administration include sterile solutions ready for injection,sterile dry soluble products, such as lyophilized powders, ready to becombined with a solvent just prior to use, including hypodermic tablets,sterile suspensions ready for injection, sterile dry insoluble productsready to be combined with a vehicle just prior to use and sterileemulsions. The solutions may be either aqueous or nonaqueous.

If administered intravenously, suitable carriers include physiologicalsaline or phosphate buffered saline (PBS), and solutions containingthickening and solubilizing agents, such as glucose, polyethyleneglycol, and polypropylene glycol and mixtures thereof.

Pharmaceutically acceptable carriers used in parenteral preparationsinclude aqueous vehicles, nonaqueous vehicles, antimicrobial agents,isotonic agents, buffers, antioxidants, local anesthetics, suspendingand dispersing agents, emulsifying agents, sequestering or chelatingagents and other pharmaceutically acceptable substances.

Examples of aqueous vehicles include Sodium Chloride Injection, RingersInjection, Isotonic Dextrose Injection, Sterile Water Injection,Dextrose and Lactated Ringers Injection. Nonaqueous parenteral vehiclesinclude fixed oils of vegetable origin, cottonseed oil, corn oil, sesameoil and peanut oil. Antimicrobial agents in bacteriostatic orfungistatic concentrations must be added to parenteral preparationspackaged in multiple-dose containers which include phenols or cresols,mercurials, benzyl alcohol, chlorobutanol, methyl and propylp-hydroxybenzoic acid esters, thimerosal, benzalkonium chloride andbenzethonium chloride. Isotonic agents include sodium chloride anddextrose. Buffers include phosphate and citrate. Antioxidants includesodium bisulfate. Local anesthetics include procaine hydrochloride.Suspending and dispersing agents include sodium carboxymethylcelluose,hydroxypropyl methylcellulose and polyvinylpyrrolidone. Emulsifyingagents include Polysorbate 80 (TWEEN® 80). A sequestering or chelatingagent of metal ions include EDTA. Pharmaceutical carriers also includeethyl alcohol, polyethylene glycol and propylene glycol for watermiscible vehicles and sodium hydroxide, hydrochloric acid, citric acidor lactic acid for pH adjustment.

The concentration of the pharmaceutically active compound is adjusted sothat an injection provides an effective amount to produce the desiredpharmacological effect. The exact dose depends on the age, weight andcondition of the patient or animal as is known in the art.

The unit-dose parenteral preparations are packaged in an ampoule, a vialor a syringe with a needle. All preparations for parenteraladministration must be sterile, as is known and practiced in the art.

Illustratively, intravenous or intraarterial infusion of a sterileaqueous solution containing an active compound is an effective mode ofadministration. Another embodiment is a sterile aqueous or oily solutionor suspension containing an active material injected as necessary toproduce the desired pharmacological effect.

Injectables are designed for local and systemic administration.Typically a therapeutically effective dosage is formulated to contain aconcentration of at least about 0.1% w/w up to about 90% w/w or more,preferably more than 1% w/w of the active compound to the treatedtissue(s). The active ingredient may be administered at once, or may bedivided into a number of smaller doses to be administered at intervalsof time. It is understood that the precise dosage and duration oftreatment is a function of the tissue being treated and may bedetermined empirically using known testing protocols or by extrapolationfrom in vivo or in vitro test data. It is to be noted thatconcentrations and dosage values may also vary with the age of theindividual treated. It is to be further understood that for anyparticular subject, specific dosage regimens should be adjusted overtime according to the individual need and the professional judgment ofthe person administering or supervising the administration of theformulations, and that the concentration ranges set forth herein areexemplary only and are not intended to limit the scope or practice ofthe claimed formulations.

The compound may be suspended in micronized or other suitable form ormay be derivatized to produce a more soluble active product or toproduce a prodrug. The form of the resulting mixture depends upon anumber of factors, including the intended mode of administration and thesolubility of the compound in the selected carrier or vehicle. Theeffective concentration is sufficient for ameliorating the symptoms ofthe condition and may be empirically determined.

3. Lyophilized Powders

Of interest herein are also lyophilized powders, which can bereconstituted for administration as solutions, emulsions and othermixtures. They may also be reconstituted and formulated as solids orgels.

The sterile, lyophilized powder is prepared by dissolving a compound offormula I in a suitable solvent. The solvent may contain an excipientwhich improves the stability or other pharmacological component of thepowder or reconstituted solution, prepared from the powder. Excipientsthat may be used include, but are not limited to, dextrose, sorbital,fructose, corn syrup, xylitol, glycerin, glucose, sucrose or othersuitable agent. The solvent may also contain a buffer, such as citrate,sodium or potassium phosphate or other such buffer known to those ofskill in the art at, typically, about neutral pH. Subsequent sterilefiltration of the solution followed by lyophilization under standardconditions known to those of skill in the art provides the desiredformulation. Generally, the resulting solution will be apportioned intovials for lyophilization. Each vial will contain a single dosage(10-1000 mg, preferably 100-500 mg) or multiple dosages of the compound.The lyophilized powder can be stored under appropriate conditions, suchas at about 4° C. to room temperature.

Reconstitution of this lyophilized powder with water for injectionprovides a formulation for use in parenteral administration. Forreconstitution, about 1-50 mg, preferably 5-35 mg, more preferably about9-30 mg of lyophilized powder, is added per mL of sterile water or othersuitable carrier. The precise amount depends upon the selected compound.Such amount can be empirically determined.

4. Topical Administration

Topical mixtures are prepared as described for the local and systemicadministration. The resulting mixture may be a solution, suspension,emulsions or the like and are formulated as creams, gels, ointments,emulsions, solutions, elixirs, lotions, suspensions, tinctures, pastes,foams, aerosols, irrigations, sprays, suppositories, bandages, dermalpatches or any other formulations suitable for topical administration.

The compounds or pharmaceutically acceptable derivatives thereof may beformulated as aerosols for topical application, such as by inhalation(see, e.g., U.S. Pat. Nos. 4,044,126, 4,414,209, and 4,364,923, whichdescribe aerosols for delivery of a steroid useful for treatmentinflammatory diseases, particularly asthma). These formulations foradministration to the respiratory tract can be in the form of an aerosolor solution for a nebulizer, or as a microfine powder for insufflation,alone or in combination with an inert carrier such as lactose. In such acase, the particles of the formulation will typically have diameters ofless than 50 microns, preferably less than 10 microns.

The compounds may be formulated for local or topical application, suchas for topical application to the skin and mucous membranes, such as inthe eye, in the form of gels, creams, and lotions and for application tothe eye or for intracisternal or intraspinal application. Topicaladministration is contemplated for transdermal delivery and also foradministration to the eyes or mucosa, or for inhalation therapies. Nasalsolutions of the active compound alone or in combination with otherpharmaceutically acceptable excipients can also be administered.

These solutions, particularly those intended for ophthalmic use, may beformulated as 0.01%-10% isotonic solutions, pH about 5-7, withappropriate salts.

5. Compositions for Other Routes of Administration

Other routes of administration, such as transdermal patches and rectaladministration are also contemplated herein.

For example, pharmaceutical dosage forms for rectal administration arerectal suppositories, capsules and tablets for systemic effect. Rectalsuppositories are used herein mean solid bodies for insertion into therectum which melt or soften at body temperature releasing one or morepharmacologically or therapeutically active ingredients.Pharmaceutically acceptable substances utilized in rectal suppositoriesare bases or vehicles and agents to raise the melting point. Examples ofbases include cocoa butter (theobroma oil), glycerin-gelatin, carbowax(polyoxyethylene glycol) and appropriate mixtures of mono-, di- andtriglycerides of fatty acids. Combinations of the various bases may beused. Agents to raise the melting point of suppositories includespermaceti and wax. Rectal suppositories may be prepared either by thecompressed method or by molding. The typical weight of a rectalsuppository is about 2 to 3 gm.

Tablets and capsules for rectal administration are manufactured usingthe same pharmaceutically acceptable substance and by the same methodsas for formulations for oral administration.

6. Articles of Manufacture

The compounds or pharmaceutically acceptable derivatives may be packagedas articles of manufacture containing packaging material, a compound orpharmaceutically acceptable derivative thereof provided herein, which iseffective for reducing serum uric levels.

The articles of manufacture provided herein contain packaging materials.Packaging materials for use in packaging pharmaceutical products arewell known to those of skill in the art. See, e.g., U.S. Pat. Nos.5,323,907, 5,052,558 and 5,033,352. Examples of pharmaceutical packagingmaterials include, but are not limited to, blister packs, bottles,tubes, inhalers, pumps, bags, vials, containers, syringes, bottles, andany packaging material suitable for a selected formulation and intendedmode of administration and treatment. A wide array of formulations ofthe compounds and compositions provided herein are contemplated fortreatment and prevention of insulin resistance.

It has recently been reported that raised uric acid levels do not impairendothelial function in humans. Waring et al., Heart 2004, 90:155-159.The inventors believe that this report does not fully reveal the effectsof raised uric acid levels in the blood. Waring et al reported that theinfusion of uric acid into the forearm vein of humans does not impairendothelial function as measured by brachial artery reactivity. However,the authors examined the effect immediately after infusion of uric acid,and it remains possible that the effect on NO production is delayed.Indeed, with experimental hyperuricemia, hypertension does not developuntil several weeks after the uric acid is raised. It is also possiblethat allopurinol may improve NO production in subjects by a differentmechanism, such as lowering xanthine oxidase-induced oxidants. Contraryto the Waring et al. report, the inventors believe that uric acid doesindeed impair endothelial dysfunction and as a result NO production isimpaired.

EXAMPLE 1 Hyperuricemia Induces Endothelial Dysfunction by Inhibitingthe Production of NO in Rats Methods

Male Sprague-Dawley rats were housed in standard conditions and fednormal diets. Hyperuricemia was induced with an uricase inhibitor,oxonic acid (OA; 750 mg/kg/day), by gavage, with control rats receivingvehicle. Allopurinol (AP) was used to block hyperuricemia by placing APin the drinking water (150 mg/L). Rats were divided into four groups:(1) Control, (2) AP only, (3) OA only, and (4) OA+AP. Systolic bloodpressure was measured using a tail-cuff sphygmomanometer. The amount ofdrinking water consumed and changes in body weight were noted. Rats weresacrificed at one and seven days. Serum was analyzed for uric acidconcentration and nitrites/nitrates (NO_(x)) by chemiluminescencemethod. (Prabhakar SS: Inhibition of mesangial iNOS by reducedextracellular pH is associated with uncoupling of NADPH oxidation.Kidney Int 61:2015-2024, 2002). Statistical analysis between subgroupswas performed using ANOVA.

Results

There was no difference in the amount of water consumed and the changein body weight between the three groups over seven days. OA induced amild hyperuricemia at both 1 day (1.7±0.7 vs. 0.8±0.4 mg/dL in OA vs.Control, p<0.05) and 7 days (1.8±0.4 vs. 0.9±0.7 mg/dL in OA vs.Control, p<0.05). AP only had a mild and non-significant effect on serumuric acid concentrations at day 1 (1.52±0.3 mg/dL, p=NS), buteffectively reversed the hyperuricemia at 7 days (0.3±0.2 mg/dL,p<0.001). Serum nitrites and nitrates (NO_(x)) were reduced by 40-50% inhyperuricemic rats at both 1 day (15.6±0.4 vs. 22.6±1.0 μmol/L in OA vs.Control, p<0.001) and 7 days (14.6±1.1 vs. 27.5±1.3 μmol/L in OA vs.Control, p<0.001). This decrease in NO_(x) was improved slightly by APat 1 day (17.4±0.8 μmol/L, p<0.001) and reversed completely at 7 days(25.0±0.8 μmol/L, p<0.001). (FIG. 1.) There was also a direct linearcorrelation between serum UA and NO_(x) (FIG. 2). Rats treated with APalone did not show a significant change in either serum UA or NO_(x)concentration. Rats treated with OA also showed a trend toward highersystolic blood pressure at 7 days (178±18 vs. 158±16 vs. 147±11 mm Hg inOA vs. Control vs. OA/AP, p=NS).

Conclusions

Most mammals have the enzyme uricase that degrades uric acid toallantoin with the generation of oxidants. In humans, uricase is mutatedresulting in higher uric acid levels. Rats administered an uricaseinhibitor (oxonic acid) develop mild hyperuricemia, hypertension, andvascular disease that is mediated by activation of the renin-angiotensinsystem, a loss of macula densa NO synthase, and the development ofmicrovascular disease (Mazzali M, Hughes J, Kim Y G, Jefferson J A, KangD H, Gordon K L, Lan H Y, Kivlighn S, Johnson R J: Elevated uric acidincreases blood pressure in the rat by a novel crystal-independentmechanism. Hypertension 38:1101-1106, 2001). In this study, it wasdemonstrated that hyperuricemic rats have a fall in serum nitrites (areflection of NO production) that is reversed by allopurinol.Furthermore, there was a direct linear correlation between serum uricacid and serum nitric oxide. The induction of hyperuricemia also showeda trend towards increased systolic blood pressure. This data shows thathyperuricemia leads to endothelial dysfunction in the rat. As discussedbriefly above, this is a contrary conclusion to that was earlierreported by Waring et al which concluded that the infusion of uric acidinto humans does not impair endothelial function (Waring WS, Adwani S H,Breukels O, Webb D J, Maxwell S R: Hyperuricaemia does not impaircardiovascular function in healthy adults. Heart 90:155-159, 2004).However, these studies did not measure nitric oxide levels nor mentioneffects of sustained hyperuricemia on endothelial-dependentvasodilatation.

Without being held to any specific mechanism, the inventors believe thatraised serum uric acid levels ultimately lead to insulin resistancemediated by impairment of endothelial function and inhibition of NOproduction. As support for this mechanistic theory, the inventors citeto Cook et al., Swiss Med Wkly, 2003, 133:360-363, which shows thatknock-out mice harboring a genetic defect for endothelial nitric oxidesynthase develop many of the abnormalities associated with the metabolicsyndrome. Accordingly, it is the inventors' position that insulinresistance results from raised serum uric acid levels, likely caused bythe high sugar, fructose-generating western diet, which results inendothelial dysfunction and inhibition of NO production, and ultimatelyto insulin resistance. Thus, controlling a person's average serum uricacid levels by administration of UALA will have the dramatic affect ofdelaying the onset of the characteristics of the metabolic syndrome,including insulin resistance.

According to another embodiment, the subject invention pertains to amethod of determining the uric acid increasing load per mass of food.The method may comprise the administration of a quantity of a food itemand determination of the affect of such administration on the uric acidlevels of such food. Thus, one or more food items are tested and theinformation is used to generate a uric acid increasing index (or ‘UAindex’). WO-A 2005040752 and U. S. Patent Pub No. 2004043106 areincorporated by reference, which describes methodology for establishingglycemic loads of foods. The teachings of such publication may be easilyadaptable to producing correlating types of information relating to UricAcid generating loads of foods, including fluids.

What is claimed is:
 1. A method of lowering uric acid levels in apatient suffering from diabetes, said method comprising: administeringto said patient a composition comprising a uric acid lowering agentaccording to a regimen effective to maintain a patient's average serumuric acid level at or below 5.5 mg/dl, wherein said uric acid loweringagent is a xanthine oxidase inhibitor, a uricosuric, a uricase, apegylated uricase, a rasburicase, a urate channel inhibitor, or a URAT-1blocker; wherein said administering treats or delays the onset of saiddiabetes.
 2. The method of claim 1, further comprising determining saidpatient's average serum uric acid prior to said administering.
 3. Themethod of claim 1, wherein said composition is administered over thecourse of at least one week.
 4. The method of claim 1, wherein saidcomposition is administered over the course of at least 2 weeks.
 5. Themethod of claim 1, wherein said composition is administered over thecourse of at least 4 weeks.
 6. The method of claim 1, wherein saidcomposition is administered according to a regimen to maintain theaverage serum uric acid level equal to or below 5.5 mg/dl for at least 2weeks.
 7. The method of claim 6, wherein regimen is designed to maintainthe average serum uric acid level equal to or below 5.5 mg/dl for atleast 4 weeks.
 8. The method of claim 6, wherein regimen is designed tomaintain the average serum uric acid level equal to or below 5.5 mg/dlfor at least 8 weeks.
 9. The method of claim 6, wherein regimen isdesigned to maintain the average serum uric acid level equal to or below5.5 mg/dl for at least 24 weeks.
 10. The method of claim 6, whereinregimen is designed to maintain the average serum uric acid level equalto or below 5.5 mg/dl for at least 2 years.
 11. The method of claim 1,wherein said composition is administered according to a regimen tomaintain average serum uric acid levels between 4.5 mg/dl to 5.5 mg/dlfor at least 12 weeks.
 12. The method of claim 11, wherein saidcomposition is administered according to a regimen to maintain averageserum uric acid levels between 4.5 mg/dl to 5.5 mg/dl for at least 1year.
 13. A method lowering uric acid levels in a patient suffering fromdiabetes comprising: determining said patient's average serum uric acidlevel; and administering to said patient a composition comprising a uricacid lowering agent according to a regimen effective to maintain saidpatient's average serum uric acid level between 4.5 mg/dl and 5.5 mg/dlfor at least 4 weeks, wherein said uric acid lowering agent is axanthine oxidase inhibitor, a uricosuric, a uricase, a pegylateduricase, a rasburicase, a urate channel inhibitor, or a URAT-1 blocker,wherein said administering treats or delays onset of said diabetes. 14.The method of claim 13, wherein said administering occurs according to aregimen effective to maintain said patient's average serum uric acidlevel between 4.5 mg/dl and 5.5 mg/dl for at least 12 weeks.
 15. Themethod of claim 13, wherein said administering occurs according to aregimen effective to maintain said patient's average serum uric acidlevel between about 4.5 mg/dl and 5.5 mg/dl for at least 36 weeks.
 16. Amethod of lowering uric acid levels in a patient suffering from diabetescomprising administering to said patient a composition comprising a uricacid lowering agent according to a regimen effective to maintain saidpatient's average serum uric acid level between 4.5 mg/dl and 5.5 mg/dlfor at least 2 weeks, wherein said uric acid lowering agent is axanthine oxidase inhibitor, a uricosuric, a uricase, a pegylateduricase, a rasburicase, a urate channel inhibitor, or a URAT-1 blocker,wherein said administering treats or delays onset of said diabetes. 17.The method of claim 1, wherein said uric acid lowering agent is axanthine oxidase inhibitor.
 18. The method of claim 20, wherein saidxanthine oxidase inhibitor is febuxostat.
 19. The method of claim 1,wherein said uric acid lowering agent is benziodarone, benzbromarone orprobenecid.
 24. The method of claim 1, wherein said uric acid loweringagent is a urate channel inhibitor.
 25. The method of claim 1, whereinsaid uric acid lowering agent is a URAT-1 blocker.